Failure to Provide Adequate Pain Management and Assessment
Penalty
Summary
The facility failed to provide adequate pain management for a resident following a fall that resulted in a right ankle fracture. Despite the resident's ongoing complaints of pain, especially during physical therapy and ambulation, there was a lack of consistent and thorough pain assessment, documentation, and follow-up. The facility's policy required assessment of pain type, frequency, intensity, and duration, as well as re-evaluation of interventions, but these steps were not consistently performed. Documentation often showed zero pain levels and no administration of pain medication, even when physical therapy notes and staff interviews indicated the resident was experiencing pain and refusing to ambulate due to discomfort. There were multiple instances where the resident's pain was not communicated to the nurse practitioner or physician, despite persistent complaints and refusal to participate in therapy. Physical therapy and CNA staff noted the resident's pain and functional decline, but this information was not always relayed to licensed nursing staff or documented in the medical record. Additionally, when pain medication was administered, there was insufficient documentation of pain reassessment to determine the effectiveness of the intervention, as required by facility policy. The lack of communication and documentation led to poor pain control and a decline in the resident's mobility. Interviews with staff confirmed that pain complaints were sometimes forgotten or not reported due to workload, and that there was a lack of awareness regarding the resident's physical restrictions and pain status. The resident's medical history included a right ankle fracture and fluctuating cognitive capacity, which further complicated assessment and management. The failure to accurately assess, document, and communicate the resident's pain, as well as to notify the appropriate medical providers, resulted in inadequate pain management and contributed to the resident's refusal to ambulate and functional decline.